International Journal of Case Reports and Images, Vol. 9, 2018. ISSN: 0976-3198 Int J Case Rep Images 2018;9:100882Z01AS2018. www.ijcasereportsandimages.com Salih et al. 1 CASE REPORT PEER REVIEWED | OPEN ACCESS Pilonidal sinus of neck: A case report Abdulwahid M. Salih, Fahmi H. Kakamad, Rawezh Q. Salih, Hiwa O. Baba, Shvan H. Mohammed, Kayhan A. Najar, Suhaib H. Kakamad, Asmaa N. Abdullah ABSTRACT Introduction: Pilonidal sinus (CPNS) is a chronic inflammatory disease resulting from hair penetration into the epidermis. Atypical pilonidal sinus is a pilonidal sinus of areas other than sacrococcygeal site. The aim of this study is to report another rare type of atypical PNS which is neck pilonidal sinus. Case Report: A 20-year-old female presented with chronic multiple sinuses in the posterior part of neck that associated with yellowish discharge for about one year. On examination, there were about 10 openings on the nape of her neck with surrounding skin erythema. The excision of sinuses was performed under local anesthesia. Wound was closed by layers, histopathological examination confirmed diagnosis of pilonidal Abdulwahid M. Salih 1 , Fahmi H. Kakamad 2,3 , Rawezh Q. Salih 3,4 , Hiwa O. Baba 3 , Shvan H. Mohammed 3 , Kayhan A. Najar 3 , Suhaib H. Kakamad 3 , Asmaa N. Abdullah 5 Affiliations: 1 Faculty of Medical Sciences, School of Medi- cine, Department Surgery, University of Sulaimani, Fran- çois Mitterrand Street, Sulaimani, Kurdistan, Iraq; 2 Faculty of Medical Sciences, School of Medicine, Department Car- diothoracic and Vascular Surgery, University of Sulaimani, François Mitterrand Street, Sulaimani, Kurdistan, Iraq; 3 Kscien Organization for Scientific Research, Hamdi street, Azay mall,Second floor, Sulaimani, Kurdistan, Iraq; 4 Shar Medical Center, Ibrahem pasha street, Sulaimani, Kurdistan, Iraq; 5 Faculty of Medical Sciences, School of Medicine, De- partment Pathology, University of Sulaimani, François Mit- terrand Street, Sulaimani, Kurdistan, Iraq. Corresponding Author: Fahmi H. Kakamad, Faculty of Medi- cal Sciences, School of Medicine, Department Cardiothorac- ic and Vascular Surgery, University of Sulaimani, François Mitterrand Street, Sulaimani, Kurdistan, Iraq; Email: fahmi. [email protected]Received: 14 November 2017 Accepted: 23 December 2017 Published: 01 February 2018 sinus. After two months of follow-up the wound was acceptable with clear margins. Conclusion: Neck PNS is another type of atypical PNS presenting with multiple discharging sinuses. Excision with primary closure is the definitive management therapy. Keywords: Atypical pilonidal sinus, Discharging sinus, Neck How to cite this article Salih AM, Kakamad FH, Salih RQ, Baba HO, Mohammed SH, Najar KA, Kakamad SH, Abdullah AN. Pilonidal sinus of neck: A case report. Int J Case Rep Images 2018;9:100882Z01AS2018. Article ID: 100882Z01AS2018 ********* doi: 10.5348/100882Z01AS2018CR INTRODUCTION Pilonidal sinus (PNS) is a chronic inflammatory disease resulting from hair penetration into the epidermis [1]. Sacrococcygeal region is the classical site of PNS [2]. Rarely, it may occur in atypical area with variable clinical course and management. The reported atypical sites of PNS are submental area [3], scalp [4], umbilicus [1], post and preauricular areas [5, 6], anal canal [7], face [8], intermammary region and axilla [9]. Different surgical and noninvasive techniques have been practiced as management strategy for sacrococcygeal PNS. Operative therapies include simple incision and drainage, marsupialization, lying open, primary closure and excision, or rhomboid excision and Limberg flap while nonoperative techniques basically compose of
Transcript
International Journal of Case Reports and Images, Vol. 9, 2018. ISSN: 0976-3198
Int J Case Rep Images 2018;9:100882Z01AS2018. www.ijcasereportsandimages.com
Salih et al. 1
CASE REPORT PEER REVIEWED | OPEN ACCESS
Pilonidal sinus of neck: A case report
Abdulwahid M. Salih, Fahmi H. Kakamad, Rawezh Q. Salih, Hiwa O. Baba, Shvan H. Mohammed, Kayhan A. Najar,
Suhaib H. Kakamad, Asmaa N. Abdullah
ABSTRACT
Introduction: Pilonidal sinus (CPNS) is a chronic inflammatory disease resulting from hair penetration into the epidermis. Atypical pilonidal sinus is a pilonidal sinus of areas other than sacrococcygeal site. The aim of this study is to report another rare type of atypical PNS which is neck pilonidal sinus. Case Report: A 20-year-old female presented with chronic multiple sinuses in the posterior part of neck that associated with yellowish discharge for about one year. On examination, there were about 10 openings on the nape of her neck with surrounding skin erythema. The excision of sinuses was performed under local anesthesia. Wound was closed by layers, histopathological examination confirmed diagnosis of pilonidal
Abdulwahid M. Salih1, Fahmi H. Kakamad2,3, Rawezh Q. Salih3,4, Hiwa O. Baba3, Shvan H. Mohammed3, Kayhan A. Najar3, Suhaib H. Kakamad3, Asmaa N. Abdullah5
Affiliations: 1Faculty of Medical Sciences, School of Medi-cine, Department Surgery, University of Sulaimani, Fran-çois Mitterrand Street, Sulaimani, Kurdistan, Iraq; 2Faculty of Medical Sciences, School of Medicine, Department Car-diothoracic and Vascular Surgery, University of Sulaimani, François Mitterrand Street, Sulaimani, Kurdistan, Iraq; 3Kscien Organization for Scientific Research, Hamdi street, Azay mall,Second floor, Sulaimani, Kurdistan, Iraq; 4Shar Medical Center, Ibrahem pasha street, Sulaimani, Kurdistan, Iraq; 5Faculty of Medical Sciences, School of Medicine, De-partment Pathology, University of Sulaimani, François Mit-terrand Street, Sulaimani, Kurdistan, Iraq.Corresponding Author: Fahmi H. Kakamad, Faculty of Medi-cal Sciences, School of Medicine, Department Cardiothorac-ic and Vascular Surgery, University of Sulaimani, François Mitterrand Street, Sulaimani, Kurdistan, Iraq; Email: [email protected]
Received: 14 November 2017Accepted: 23 December 2017Published: 01 February 2018
sinus. After two months of follow-up the wound was acceptable with clear margins. Conclusion: Neck PNS is another type of atypical PNS presenting with multiple discharging sinuses. Excision with primary closure is the definitive management therapy.
Salih AM, Kakamad FH, Salih RQ, Baba HO, Mohammed SH, Najar KA, Kakamad SH, Abdullah AN. Pilonidal sinus of neck: A case report. Int J Case Rep Images 2018;9:100882Z01AS2018.
Article ID: 100882Z01AS2018
*********
doi: 10.5348/100882Z01AS2018CR
INTRODUCTION
Pilonidal sinus (PNS) is a chronic inflammatory disease resulting from hair penetration into the epidermis [1]. Sacrococcygeal region is the classical site of PNS [2]. Rarely, it may occur in atypical area with variable clinical course and management. The reported atypical sites of PNS are submental area [3], scalp [4], umbilicus [1], post and preauricular areas [5, 6], anal canal [7], face [8], intermammary region and axilla [9].
Different surgical and noninvasive techniques have been practiced as management strategy for sacrococcygeal PNS. Operative therapies include simple incision and drainage, marsupialization, lying open, primary closure and excision, or rhomboid excision and Limberg flap while nonoperative techniques basically compose of
International Journal of Case Reports and Images, Vol. 9, 2018. ISSN: 0976-3198
Int J Case Rep Images 2018;9:100882Z01AS2018. www.ijcasereportsandimages.com
Salih et al. 2
injection of different sclerosing and wound enhancing preparations into the sinus tract. The management of atypical PNS is more specific which includes resection with or without primary closures. Postoperative complications and recurrence are not uncommon. Primary risk factors for complications and recurrence have been explained in a number of researches such as obesity, family history, male gender, tobacco, poor hygiene, size of sinus, and the surgical methods [3].
Pilonidal sinus of the neck is a very rare disease with only two reported cases in literature. The aim of this study is to present and discuss a case of neck PNS with brief review of literature.
CASE REPORT
A 20-year-old female presented with chronic multiple sinuses in the posterior part of neck that associated with yellowish discharge for about one year. On examination, there were about 10 openings on the nape of her neck with 7x4 cm induration and surrounding skin erythema (Figure 1). The diagnosis of PNS of atypical area was suspected. Excision of sinuses was performed under local anesthesia. Wound was closed by layers, corrugate drain was put. Histopathological examination showed a tract formed by invaginated epidermis extending from the skin to the subcutaneous tissue. Cross section of the tract revealed free hair shaft embedded in heavy chronic inflammation and granulation tissue reaction (Figure 2). After two months of follow-up the wound was healthy with clear margins (Figure 3).
DISCUSSION
Reporting of pilonidal sinus in atypical area has started to increase in the last few decades [10]. Our previous
Figure 2: Skin and subcutaneous tissue revealing a deep dermal sinus lined by foreign body granulomas with granulation.
Figure 1: Multiple opening on the nape of the patient with surrounding erythema.
systematic review showed that about 10 sites other than sacrococcygeal region have been affected in more than 300 patients [10]. Although etiology and presentation might be similar, atypical PNS differs from classical one in several aspects. The diagnosis of sacrococcygeal PNS is clinical and does not need detailed investigations. When it occurs in other areas, PNS may present challenge to the treating physician [10]. Among 12 cases of intermammary PNS reported by Shareef et al. only three of them (25%) were diagnosed preoperatively [9]. Pilonidal sinus of areas other than sacrococcygeal region could be
International Journal of Case Reports and Images, Vol. 9, 2018. ISSN: 0976-3198
Int J Case Rep Images 2018;9:100882Z01AS2018. www.ijcasereportsandimages.com
Salih et al. 3
misdiagnosed as hernia, endometriosis, urachal cyst, epidermoid cyst, pyogenic granuloma, dermoid cyst and infected sebaceous cyst [10]. The strategy of management is another difference between classical and atypical PNS. None of the conservative therapy has been tried and well-studied in the management of atypical PNS. This may be due to rarity of the condition and/or missing the diagnosis in the first place [10, 11]. The most common sites for PNS apart from sacrococcygeal region (atypical PNS), in order of frequency are umbilicus (90%), hand (3.9%), scalp (1.7), perianal anal region (1.3%), intermammary area (1%), face (0.7%), periareolar (0.3%), penis (0.3%), clitoris (0.3%) and prepuce (0.3%). Neck PNS is only reported twice in literature [10].
For the first time, at 1992, Miyata et al. reported a PNS in the neck of a 21-year-old obese, otherwise healthy male. The patient presented to them with 7 cm sized, left nuchal abscess. The condition started before four years and five times underwent drainage in three different centers and recurred. None of them reached the correct diagnosis. The patient was cured from the disease after total excision and direct closure of the wound and histopathological examination confirmed the diagnosis of atypical PNS [12].
The second and the last case of neck PNS was reported by Meher et al. In their paper, they presented a 24-year-old male complaining from chronic discharging sinuses on the right side of upper neck for about three years. The surrounding skin showed scaring and thickening. The provisional diagnosis was non-specific discharging sinus. After injection of methylene blue, excision of the sinus was performed in toto and the wound was closed. The histopathological examination showed features consistent with pilonidal sinus [13].
The previous two reported cases of neck PNS showed multiple discharging sinuses which is similar to our findings [12, 13]. There were more than 10 openings on the
nape of the patients. Being multiple might be regarded as characteristic of neck PNS. Previous surgeon did not put neck PNS in the list of the differential diagnoses while we did as the diagnosis of atypical PNS has been increased in the last few decades especially in our locality [12, 13]. We have learned to put atypical PNS as the one of the differential diagnoses of every dermatological problem presenting with chronic discharging. Total resection and primary closure cured the previous two cases of neck PNS [12, 13]. The current case was managed with excision as well as primary closure.
CONCLUSION
In conclusion, neck pilonidal sinus (PNS) is another type of atypical PNS presenting with multiple discharging sinuses. Excision with primary closure is the definitive management therapy.
REFERENCES
1. Salih AM, Kakamad FH, Essa RA, et al. Pilonidal sinus of the umbilicus: Presentation and management. Edorium J Gastrointest Surg 2017;4:1–4.
2. Al-Naami MY. Outpatient pilonidal sinotomy complemented with good wound and surrounding skin care. Saudi Med J 2005 Feb;26(2):285–8.
3. Salih AM, Kakamad FH, Habibullah IJ, Abdulqadr MH. Submental pilonidal sinus: The first reported case. Pilonidal Sinus Journal 2017;20:3(1):4.
4. Salih AM, Kakamad FH. Scalp pilonidal sinus: A case report. Int J Case Rep Images 2016;13;7(3):175–7.
5. Salih AM, Kakamad FH. Preauricular pilonidal sinus: The first reported case. Int J Case Rep Images 2016;27;7(3):162–4.
6. Kakamad FH, Salih AM, Mohammed SH, Dahat AH Lhun TH. Postauricular pilonidal sinus: A case report with literature review. Pilonidal Sinus Journal 2017;12:3(1):4.
7. Salih AM, Kakamad FH. A case report of endoanal pilonidal sinus. J Case Rep Images Surg 2016;24;2:60–2.
8. Salih AM, Kakamad FH, Essa RA, et al. Pilonidal sinus of the face: Presentation and management - a literature review. Pilonidal Sinus Journal 2017;3(1):9–13.
9. Shareef SH, Hawrami TA, Salih AM, et al. Intermammary pilonidal sinus: The first case series. Int J Surg Case Rep 2017;41:265–8.
10. Salih AM, Kakamad FH, Essa RA, et al. Pilonidal sinus of atypical areas: Presentation and management. Pilonidal Sinus Journal 2017;3(1):8–14.
11. Salih AM, Kakamad FH, Salih RQ, Mohammed SH, Habibullah IJ, Hammood ZD. Non-operative management of pilonidal sinus disease; one more step towards the ideal management therapy; a randomized controlled trial. Surgery. Article in press.
12. Miyata T, Toh H, Doi F, Torisu M. Pilonidal sinus on the neck. Surg Today 1992;22(4):379–82.
13. Meher R, Sethi A, Sareen D, Bansal R. Pilonidal sinus of the neck. J Laryngol Otol 2006 Feb;120(2):e5.
Figure 3: Healthy scar after two months of excision and primary closure.
International Journal of Case Reports and Images, Vol. 9, 2018. ISSN: 0976-3198
Int J Case Rep Images 2018;9:100882Z01AS2018. www.ijcasereportsandimages.com
Salih et al. 4
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Author ContributionsAbdulwahid M. Salih – Substantial contributions to conception and design, Acquisition of data, Analysis and interpretation of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be publishedFahmi H. Kakamad – Substantial contributions to conception and design, Analysis and interpretation of data, Drafting the article, Final approval of the version to be publishedRawezh Q. Salih – Substantial contributions to conception and design, Acquisition of data, Analysis and interpretation of data, Revising it critically for important intellectual content, Final approval of the version to be publishedHiwa O. Baba – Substantial contributions to conception and design, Acquisition of data, Revising it critically for important intellectual content, Final approval of the version to be publishedShvan H. Mohammed – Substantial contributions to conception and design, Acquisition of data, Revising it critically for important intellectual content, Final approval of the version to be publishedKayhan A. Najar – Substantial contributions to conception and design, Acquisition of data, Revising it critically for important intellectual content, Final approval of the version to be published
Suhaib H. Kakamad – Acquisition of data, Drafting the article, Final approval of the version to be publishedAsmaa N. Abdullah – Analysis and interpretation of data, Revising it critically for important intellectual content, Final approval of the version to be published
Guarantor of SubmissionThe corresponding author is the guarantor of submission.
Source of SupportNone
Consent StatementWritten informed consent was obtained from the patient for publication of this case report.
Conflict of InterestAuthors declare no conflict of interest.
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